Q. So you have just been told that you have prostate cancer. Your doctor recommends surgery or radiation. What does this mean?
A. Although radical (RPLND—radical prostatectomy and lymph node dissection), Robotic (DaVinci) prostatectomy, proton beam radiation therapy and intensity modulated radiation therapy (IMRT) are recognized treatments for prostate cancer, they may not be for everyone. Why? Because the side effects are considerable and life-changing with very high risks of at least temporary incontinence and up to two years of erectile dysfunction (ED). Additionally, surgery and radiation can cause bowel problems, keep you in the hospital for 4-5 days and in recovery for 4-6 weeks, and cause significant penile shrinkage and decreased sensation. These treatments are also not perfect and up to 15% of men experience recurrent prostate cancer despite surgery or radiation.
Q. But it’s cancer, so why shouldn’t I take out the prostate for a cure?
A. Usually true. However….. Prostate cancer is one of those diseases that occurs in almost everybody. Lets qualify that—at the age of 80, 80% of men have prostate cancer, at the age of 90, 90% of men have prostate cancer. You get the picture. Most men with prostate cancer die with it not of it. So a diagnosis of prostate cancer must be considered in light of other factors. I will list them now:
1) A family history of prostate cancer that caused the death of a father or brother carries a higher risk of serious prostate cancer
2) African-american race. These men have a higher risk of aggressive cancers or metastases.
3) Pathology or genomic scoring of biopsy samples indicating an aggressive prostate cancer. A Gleason score of 8 or above on a biopsy or a genomic risk score above “intermediate” suggests more aggressive disease.
4) Prostate cancers that present with metastases to bone or lymph nodes or have spread outside the prostate capsule (extracapsular extension or ECE) or have invaded the seminal vesicles (seminal vesicle invasion or SVI) require chemotherapy or hormonal therapy as they have spread beyond the confines of the prostate organ
If these factors are absent—in other words—if you have low to intermediate prostate cancer confined to the gland and do not have serious risk factors, you can consider “focal therapy” to treat your prostate cancer.
Q. What is focal therapy and why should I consider it?
A. Focal therapy of the prostate gland involves destroying the tumor without removal of the entire gland. Similar to lumpectomy in the breast, focal therapy in the prostate only treats the visible cancer and leaves the rest of the prostate alone. Reasons to consider focal therapy are twofold. First, the risk of erectile dysfunction, incontinence and other side effects are almost zero. The procedure is done as an outpatient and you can go home the day of the procedure and go back to work the next day. Secondly, even if focal therapy fails, you can still undergo surgery or radiation therapy or repeated focal therapy at a later date. Focal therapy involves heating or cooling the tumor until it dies. Specific energies include cryotherapy (freezing), focal laser ablation (FLA), microwave ablation, radiofrequency ablation, and irreversible electroporation (IRE). These treatments are done with ultrasound or MRI guidance and with transrectal (probe in the rectum) or transperineal (the skin between the scrotum and anus) needle placement.
Read more on Dr. Eric Walser’s interview about MRI-guided interventions to treat prostate cancer.
Q. Why have I never heard of this? Why does my urologist tell me to avoid focal therapies?
A. Here again, the answers are multiple. First, focal therapy is fairly new—only practiced since the late 1990’s. We do not have 10 year data on the recurrence rate of cancer after focal therapies. Cryotherapy has been around the longest and, fortunately, the risk of recurrent cancer after cryotherapy is similar to that of surgery. We expect that FLA will also be as good as surgery or radiation in properly selected individuals. Secondly, many urologists believe that prostate cancer is “multifocal”, that is, arises in multiple locations throughout the gland. They believe that only total gland removal will cure this disease. However, newer research does not support this claim. Prostate cancers that metastasize to the bones or lymph nodes show identical genetic makeup in the prostate and in the metastases. This “monoclonal” theory points to a single “index” lesion in the prostate as being responsible for the spread of disease. In other words, although you may have multiple cancers in your prostate, it seems that only one is a potential killer. The others are indolent and will likely never spread outside the prostate. Thirdly, urologists derive a large portion of their income from prostatectomies and radiation and it takes big money to buy robots for surgery or machines to deliver radiation. Need I say more?
Q. My urologist says that my PSA is high and I need a 12 core TRUS (transrectal ultrasound guided biopsy). Should I do this?
A. Most emphatically NO! The prostate is the only organ in the human body that is punished for the historical lack of a good imaging technique to see cancer—like mammography for breast cancer. The primitive state of diagnosis was “blind” biopsy of the prostate every year in men with prostate cancer until a diagnosis was made. Often, prostate cancers in unusual locations were NEVER diagnosed by these blind biopsies over 3,4, 5 and even 6 years of so-called “active surveillance”. I see men’s prostates after 5 years of “active surveillance” and there is hemorrhage and scarring from multiple blind biopsies—all of which completely missed the cancer obvious by MRI imaging. Well, now that has all changed for the better for men. Three tesla MRI and multiparametric prostate MRI (mpMRI) has 85-90% sensitivity for detecting prostate cancer. There is no longer a need to blindly stab men’s prostates yearly to find cancers—many of which are clinically insignificant. State of the art MRI will essentially replace this barbaric practice in the next 5 years. In Europe, MRI has already supplanted blind biopsies as the procedure of choice in men with elevated PSA levels. America will undoubtedly follow reluctantly, held back because of political and monetary reasons.
Q. Why are focal therapies safer?
A. The safest is probably FLA as the laser ablation monitors the temperature of the prostate, the nerve bundles, urethra and rectum so that the tumor is precisely ablated without damage to the other sensitive structures. In fact, FLA was initially invented to treat small brain tumors because of its precision and safety. Cryotherapy is effective but best suited to larger tumors because it makes a larger ablation but is less precise. Both therapies are done at UTMB in the MRI environment. This is advantageous as there is no radiation involved and both are quite safe. Cryotherapy requires an overnight stay in the hospital but FLA is done as an outpatient and you can leave around 3 pm and stay overnight in a hotel room and check in with us in the morning before going home.
Q. How can I change my diet to reduce chances of new prostate cancers or help slow down the cancer I have?
A. Many men attest to vegan diets as a way to prostate health. Certainly, avoiding red meat has been shown to reduce prostate cancer. Try to eat fruits and vegetables rich in anti-oxidants, like pomegranates and tomatoes. There is no evidence that selenium, saw palmetto, or CoEnzyme Q. reduce the risk of prostate cancer.